Consolidate and scale encounter operations

Manage the end-to-end encounter submission lifecycle, for all managed care programs, through a single platform.

Encounter Management

Health plans operating in Medicare Advantage, managed Medicaid, dual eligible and Marketplace lines of business are constantly challenged by disparate encounter systems and manual processes. These challenges lead to reduced scalability, increased costs, financial penalties and lower risk-adjusted revenue. Overcoming these impediments requires a singular encounter management platform that spans all managed care lines of business, is designed to scale to fit the needs of the business and works to ensure complete revenue integrity.

Our Approach

Edifecs Encounter Management delivers a consolidated platform that ensures the accuracy, completeness and timeliness of encounter data submissions across all managed care programs and lines of business. Health plans are able to manage all aspects of RAPS/EDPS submission and reconciliation, state-specific Medicaid encounters, dual eligibles and the Marketplace (via the Edge Server) without the IT cost and complexity of operating multiple systems. Integrated exception management workflows enable the rapid correction and re-submission of rejected encounters. Best-in-class services and hosting options ensure program performance and compliance.


Consolidate Operations

Enable a single encounter management platform for all LOBs.

  • Streamline Medicare Advantage RAPS and EDPS submissions and reconciliation to improve first-pass rate accuracy, visibility and tracking.
  • Leverage state-specific managed Medicaid encounter modules, complete with companion guides and business rules, to address individual state requirements.
  • Operationalize configurations to support both dependent and non-dependent "duals" models across states.
  • Ensure complete and accurate Edge Server submissions for both state-based and FFM models.

Ensure Accuracy

Improve first-pass submission rates and reduce encounter exceptions.

  • Deploy pre-built, up-front validations to ensure reasonable submissions of encounter data.
  • Automate the review and flagging of inaccuracies to data elements prior to submission (i.e. - place of service, provider NPI and taxonomies, diagnosis codes, HCPCS, etc.).
  • Manage the differing state/CMS requirements to submit adjustments and voids and avoid duplicate submissions.
  • Enable reporting to provide oversight of data submissions across providers and review acceptance/rejection rates.

Completeness and Timeliness

Ensure encounter data submission completeness and SLA adherence.

  • Enable the intake of transactions from multiple sources (such as core claims systems and supplemental linked/unlinked transaction) to ensure all applicable data is assimilated.
  • Consolidate inbound encounters received from delegated vendors for oversight and timely submissions. Delays can directly impact health plan quality measures.
  • Ensure the receipt of supplemental data to correct/append to any data originally submitted to support payment adjustments and risk adjustment factors.
  • Operationalize the intake and generation of compliant outbound encounters within client/state-derived SLA's.

Program Performance

Ensure program performance and compliance

  • Continuous monitoring of encounter data accuracy
  • Single-tenant hosting
  • Extend internal IT staff with Edifecs SMEs
  • Edifecs-managed software updates to maintain compliance
  • Security and certifications (including HITRUST)